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| Background / Evidence
of Need |
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The following is based upon Richard S. Dick, Elaine B. Steen,
and Don E. Detmer, Editors; Committee on Improving the Patient Record,
Institute of Medicine (1997): The Computer-Based Patient Record: An
Essential Technology for Health Care, Revised Edition. Table 1.1,
p. 60.
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Out of 1,149 patient visits in five outpatient
U.S. Army facilities:
- 11% of patients had no past medical data available
- 5-20% of charts had information missing:
- 75% of missing data were laboratory test results or reports
of radiologic examinations
- 25% of missing data were lost, incomplete, or illegible
data from previous visits
- 13-79% of laboratory results were not placed in the record
- 10-49% of visits did not have a well-defined problem in the
record
- 6-49% of visits did not have a well-defined treatment in the
record
- 40-73% of records did not have evidence of general medical information
useful for preventive medicine
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In another study:
- 10% of patient ages were not recorded
- 30% of episodes had no therapeutic agent recorded; of those
recorded, 75% were missing the amount prescribed, and 80% were
missing dosages
- 40% of episodes had no diagnosis recorded
- 60% of males and 77% of females had no occupation recorded
- 99% of males and 21% of females had no marital status recorded
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Out of 51 tape-recorded physician-patient encounters
in a pediatric clinic, percent present on tape and absent on record:
- 6% of reason for visit
- 10% of degree of disability
- 12% of allergies
- 22% of compliance data
- 31% of indications for follow-up
- 51% of cause of illness
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Out of 59 patient encounters in family medicine
clinics:
- 41% of problems identified by observers were not recorded
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